CMS Update: Pathways for Specialty Care Coordination and Integration in Population-based Models

The Centers for Medicare and Medicaid (CMS) recently released a blog on specialty care and its alignment with total cost of care models. While we have seen the Centers for Medicare and Medicaid Innovation (CMMI) experiment with specialty-based models via the Bundled Payment programs and have seen cost reductions and quality improvements in certain episodes, there is still room for specialty care participation in full network-based models. CMS/CMMI conducted a listening tour and captured some of the top concerns of integrating specialty care into ACO models:

  • Lack of actionable data to inform referrals of high clinical value and the (lack of) accountability for closing the referral loop
  • Bundle vs ACO model crossover issues – “who gets the attribution and the savings when incurred?”
  • Awareness that highly specialized conditions, like oncology episodes and renal/kidney episodes, require the specialist to take on a primary-care-like role and incentive alignment to these providers should be recognized
  • Integrating specialty care into primary care pathways should not be a threat to PCP ownership of the navigation pathway but complementary to effective management of the episode

Similar to CMMI’s Strategic Refresh release in October 2021 with a corresponding update to Direct Contracting with ACO REACH. This notice of focus may be a precursor to a CMS/CMMI model announcement that supports relief of these top concerns. Lumeris continues to focus on supporting CMS, CMMI, and our provider partners to succeed and welcome continued innovation across the continuum of care. Click here to read the full CMS update.

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